Physiology of the Respiratory Drive in ICU Patients: Implications for Diagnosis and Treatment

Jonkman, Annemijn H.; Vries, Heder de; Heunks, Leo

doi:10.1186/s13054-020-2776-z

Cited by 67 publications

(53 citation statements)

References 51 publications

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“…To achieve these goals, inspiratory ventilator settings can be adjusted to (1) modulate the patient's inspiratory effort, (2) minimize the dynamic lung stress, and (3) prevent or correct patient-ventilator dyssynchrony or any form of mismatch between needs and support. Titrating the inspiratory ventilator settings to optimize respiratory effort requires a thorough understanding of the control of breathing under mechanical ventilation [32,33], acknowledging that the control of breathing system responds to changes in ventilatory demands by modifying inspiratory effort (and thus tidal volume) to a greater extent than respiratory rate [34]. Therefore, the inspiratory ventilator settings will affect the inspiratory effort by modifying the delivered tidal volume, and thus, in spontaneously breathing patients, increasing pressure or volume assist will increase the delivered tidal volume and reduce the inspiratory effort (as respiratory drive depends mainly on the chemoreflex control of arterial pH).…”

Section: Inspiratory Ventilator Settingsmentioning

confidence: 99%

“…Excessive assist, resulting in a tidal volume that is higher than the patient's demands, may almost abolish the patient's the inspiratory effort, and as such promote diaphragmatic atrophy. However, increasing inspiratory support may not attenuate inspiratory effort in the presence of high respiratory drive due to stimuli other than arterial pH/PaCO 2 , such as pain, anxiety, or stimulation of peripheral lung receptors by lung edema or inflammation [32]. In such case, transpulmonary pressure (and hence dynamic lung stress) may progressively increase with increasing inspiratory support.…”

Section: Inspiratory Ventilator Settingsmentioning

confidence: 99%

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Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

et al. 2020

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Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO 2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.

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Section: Inspiratory Ventilator Settingsmentioning

confidence: 99%

Section: Inspiratory Ventilator Settingsmentioning

confidence: 99%

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

et al. 2020

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“…The post-inspiratory complex, which controls the transition from inspiration to expiration, could act to limit expiratory flow, mimicking expiratory airflow obstruction. 14,15 SARS-CoV-2 is a neurotropic virus and could impact the respiratory centers directly. We think this explanation is unlikely since it would not also explain the elevation in inspiratory P resist .…”

Section: Discussionmentioning

confidence: 99%

Ventilated Patients With COVID-19 Show Airflow Obstruction

Koppurapu

Puliaiev

Doerschug

et al. 2021

J Intensive Care Med

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Objective: Many patients with coronavirus disease 2019 (COVID-19) need mechanical ventilation secondary to acute respiratory distress syndrome. Information on the respiratory system mechanical characteristics of this disease is limited. The aim of this study is to describe the respiratory system mechanical properties of ventilated COVID-19 patients. Design, Setting, and Patients: Patients consecutively admitted to the medical intensive care unit at the University of Iowa Hospitals and Clinics in Iowa City, USA, from April 19 to May 1, 2020, were prospectively studied; final date of follow-up was May 1, 2020. Measurements: At the time of first patient contact, ventilator information was collected including mode, settings, peak airway pressure, plateau pressure, and total positive end expiratory pressure. Indices of airflow resistance and respiratory system compliance were calculated and analyzed. Main Results: The mean age of the patients was 58 years. 6 out of 12 (50%) patients were female. Of the 21 laboratory-confirmed COVID-19 patients on invasive mechanical ventilation, 9 patients who were actively breathing on the ventilator were excluded. All the patients included were on volume-control mode. Mean [±standard deviation] ventilator indices were: resistive pressure 19 [±4] cmH2O, airway resistance 20 [±4] cmH2O/L/s, and respiratory system static compliance 39 [±16] ml/cmH2O. These values are consistent with abnormally elevated resistance to airflow and reduced respiratory system compliance. Analysis of flow waveform graphics revealed a pattern consistent with airflow obstruction in all patients. Conclusions: Severe respiratory failure due to COVID-19 is regularly associated with airflow obstruction.

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“…In the physiological state, the respiratory drive is mainly regulated by the cerebral cortex, metabolic feedback, and chemical feedback, among which chemical feedback of blood PaCO 2 /pH level plays a dominant role ( 51 ). In some cases, however, dyspnea symptoms are not significantly alleviated, even when effective oxygenation and decarbonation are attained with the support of VV-ECMO ( 52 ).…”

Section: Monitoring and Modulation Of Respiratory Drivementioning

confidence: 99%

Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration

et al. 2021

Front. Med.

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With the goal of protecting injured lungs and extrapulmonary organs, venovenous extracorporeal membrane oxygenation (VV-ECMO) has been increasingly adopted as a rescue therapy for patients with severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation failed to provide effective oxygenation and decarbonation. In recent years, it has become a promising approach to respiratory support for awake, non-intubated, spontaneously breathing patients with respiratory failure, referred to as awake ECMO, to avoid possible detrimental effects associated with intubation, mechanical ventilation, and the adjunctive therapies. However, several complex clinical issues should be taken into consideration when initiating and implementing awake ECMO, such as selecting potential patients who appeared to benefit most; techniques to facilitating cannulation and maintain stable ECMO blood flow; approaches to manage pain, agitation, and delirium; and approaches to monitor and modulate respiratory drive. It is worth mentioning that there had also been some inherent disadvantages and limitations of awake ECMO compared to the conventional combination of ECMO and invasive mechanical ventilation. Here, we review the use of ECMO in awake, spontaneously breathing patients with severe ARDS, highlighting the issues involving bedside clinical practice, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.

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Physiology of the Respiratory Drive in ICU Patients: Implications for Diagnosis and Treatment

Cited by 67 publications

References 51 publications

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

Ventilated Patients With COVID-19 Show Airflow Obstruction

Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration

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